Postoperative Systemic Steroid Use in Rhinosinusitis According to EPOS 2020
A short course of systemic corticosteroids postoperatively does not improve quality of life in chronic rhinosinusitis patients, but may be beneficial in specific cases such as allergic fungal rhinosinusitis (AFRS) where it can reduce recurrence rates. 1
General Recommendations for Postoperative Systemic Steroid Use
- Postoperative systemic corticosteroids have not been shown to significantly improve SNOT-22 scores at 1,3, or 6 months after surgery in general chronic rhinosinusitis with nasal polyps (CRSwNP) patients 1
- Two randomized controlled trials (118 postoperative CRSwNP patients) showed no significant differences in SNOT-22 in the first 2-3 months after surgery with systemic steroid use 1
- Short courses of systemic corticosteroids can be associated with adverse effects including insomnia, mood changes, gastrointestinal issues, and rarely more serious complications like avascular necrosis 1
- The EPOS 2020 steering group suggests that 1-2 courses of systemic corticosteroids per year can be a useful addition to nasal corticosteroid treatment in patients with partially or uncontrolled disease 1
Special Considerations for AFRS Patients
- In allergic fungal rhinosinusitis (AFRS) patients, postoperative systemic corticosteroids have shown significant benefits 1
- Postoperative systemic corticosteroids improve short-term outcomes in AFRS (Level 1b evidence) 1
- Postoperative systemic corticosteroids are likely to reduce long-term recurrence in AFRS (Level 2b evidence) 1
- A randomized controlled trial by Prasad et al. showed that a 6-month postoperative corticosteroid regimen in AFRS patients was associated with less recurrence (10%) compared to a 2-month taper (30%) 1
Dosing Protocols for Postoperative Steroids
For General CRSwNP Patients (when indicated):
- Short course of prednisolone 30-60mg daily for 7-14 days with appropriate tapering 1
- Example regimen: Prednisolone 60mg daily for 7 days, then reduced to 10mg every other day, stopping on day 17 1
For AFRS Patients:
- Longer and more gradual tapering is recommended 1
- Example regimen: Prednisolone 1mg/kg/day for 1 week preoperatively and 0.5mg/kg/day for 4 weeks postoperatively, then 0.4mg/kg/day for 4 weeks, tapered to 0.2mg/kg/day for 2 months and to 0.1mg/kg/day for the last 2 months 1
- Alternative regimen: Oral prednisolone 50mg daily for 6 weeks, followed by an additional 6-week taper 1
Risks and Adverse Effects
- Common adverse effects include weight gain, Cushingoid features, mood changes, and insomnia 2, 3
- Five out of 12 patients in one study developed Cushingoid features and one developed steroid-induced diabetes mellitus after 6 weeks of prednisolone 50mg daily 1
- Rare but serious complications can include avascular necrosis and increased risk of infections 1, 3
- Systemic corticosteroids can suppress the immune system and increase risk of infection with any pathogen 3
- Increased risk of wound infections and impaired wound healing has been reported in some surgical contexts 4, 5
Practical Recommendations for Steroid Tapering
- Abrupt discontinuation should be avoided to prevent adrenal insufficiency 2, 3
- Gradual tapering allows the hypothalamic-pituitary-adrenal axis to recover 2
- For short courses (less than 3 weeks), tapering may not be necessary unless high doses were used 3
- For longer courses, a more gradual taper is recommended to minimize withdrawal symptoms 3
Common Pitfalls to Avoid
- Avoid prolonged use of systemic steroids when intranasal corticosteroids may be sufficient 6
- Do not use systemic steroids without considering potential contraindications such as uncontrolled diabetes, active infections, or psychiatric disorders 3
- Ensure proper patient education about the importance of completing the full taper rather than stopping abruptly 2
- Monitor for steroid-related complications, especially in patients on longer courses 2, 3
- Do not rely solely on systemic steroids without appropriate local therapy (intranasal corticosteroids) 1